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Treatment options based on the extent of gallbladder cancer

The extent of a gallbladder cancer is an important factor in determining treatment options. Doctors use the TNM system to formally stage the cancer (as described in “How is gallbladder cancer staged?”). But for treatment purposes, doctors generally divide gallbladder cancers into 2 groups:

Resectable cancers are those that doctors believe can be removed completely by surgery, based on the results of imaging tests and other tests.

Unresectable cancers have spread too far or are in too difficult a place to be removed entirely by surgery.

In general, some cancers that have not spread far beyond the gallbladder may still be treatable by surgery, unless the cancer has spread into major blood vessels. For instance, if the cancer has only invaded the liver in one area and not too deeply, it may be possible to remove all of the cancer by surgery. On the other hand, if the cancer has spread to both sides of the liver, to the lining of the abdominal cavity, to organs far away from the gallbladder, or if it surrounds a major blood vessel, surgery is unlikely to remove it all.

In terms of stages, stage I and II cancers and some stage III cancers may be resectable. Still, other factors, such as whether a person is healthy enough for surgery, can affect whether it’s a good option.

How the cancer is first found can also affect treatment options. For example, some cancers are found on imaging tests before surgery, while others are discovered only after surgery is done to treat another condition such as gallstones.

If gallbladder cancer is suspected or diagnosed, it’s a good idea to be seen by a surgeon with experience treating this type of cancer. Gallbladder cancer is uncommon, and not all surgeons are skilled at the more extensive operations needed to treat this cancer.

No matter what stage the cancer is, it’s very important that you understand the goal of treatment before it starts – whether it’s to try to cure the cancer or to help relieve symptoms – as well as the likelihood of the benefits and risks. This can help you make an informed decision when looking at your treatment options.

Potentially resectable gallbladder cancers

These are earlier stage cancers that doctors believe can be removed completely by surgery. Treatment of these cancers depends in part on how they are first found.

Cancer found after surgery for another gallbladder problem

Some gallbladder cancers are found when the gallbladder is removed to treat gallstones or chronic inflammation. The gallbladder is then looked at under a microscope in the lab, at which time the cancer is discovered. These are typically early stage cancers. If the cancer is confirmed to be only in the inner layers of the gallbladder (T1a), with no signs of spread outside the gallbladder, no further treatment may be needed, as there is a very good chance that all of the cancer was removed.

If the cancer is found to be more extensive within the gallbladder (T1b or greater), other tests will be done to look for any remaining cancer in the body and to determine if it is resectable. These tests may include CT or MRI scans and a staging laparoscopy.

If the cancer is thought to be resectable after these tests, a more extensive operation will be done to remove part of the liver, nearby lymph nodes, and possibly parts of the bile duct. (If the initial surgery was a laparoscopic cholecystectomy, the skin around the original incision sites may be removed as well.) This may be followed by chemotherapy (chemo), with or without radiation, to try to prevent the cancer from coming back, but it’s not clear how helpful this is.

If the imaging tests or staging laparoscopy show that the cancer can’t be resected, the treatment will be the same as described for unresectable cancers.

Cancer found during surgery for another gallbladder problem

In some cases, gallbladder cancer is discovered during a simple cholecystectomy. The surgeon finds areas that look suspicious for cancer during the operation and sends samples to the lab to be checked quickly. Cancer cells are seen in the samples while the operation is still going on.

If the surgeon is experienced in treating gallbladder cancer and believes the cancer is resectable, he or she may change the operation to a more extensive operation called an extended cholecystectomy. (See the section “Surgery for gallbladder cancer.”)

If the surgeon isn’t experienced in treating gallbladder cancer or isn’t sure if the cancer is resectable, the operation may be stopped at this point. Other tests such as CT or MRI scans will then be done to look for any remaining cancer in the body and to determine whether or not it is resectable.

If the cancer is thought to be resectable after these tests, a more extensive operation will be done to remove part of the liver, nearby lymph nodes, and possibly parts of the bile duct. This may be followed by chemotherapy, with or without radiation, to try to prevent the cancer from coming back, but it’s not clear how helpful this is.

If the scans show that the cancer can’t be resected, the treatment will be the same as described for unresectable cancers.

Cancer found on imaging tests or because of symptoms

Sometimes, gallbladder cancer is suspected because a person is having symptoms such as jaundice. Imaging tests may then detect areas suspicious for cancer on or near the gallbladder. Further imaging tests and staging laparoscopy may be done to look for any other suspicious areas in the body. These tests can help the doctor determine if these areas are cancer and whether or not it is resectable.

If the cancer is thought to be resectable and the patient is healthy enough for surgery, an extended cholecystectomy (removing the gallbladder, part of the liver, nearby lymph nodes, and possibly the bile duct and other nearby organs) is the preferred treatment. If the patient has jaundice before the surgery, a stent or catheter may be placed in the bile duct first to allow the bile to flow. This can help relieve symptoms over a few days and might make a person healthy enough for the operation. After the surgery, doctors may advise chemotherapy, with or without radiation, to try to lower the chance the cancer will come back, but it’s not clear how helpful this is.

If the imaging tests or a staging laparoscopy show that cancer is likely but that it can’t be resected, a biopsy may be done to confirm the diagnosis. Treatment will then be the same as described for unresectable cancers.

Unresectable gallbladder cancers

If the doctor feels that surgery is not a good option (for example, because of the size or location of the cancer or because of a person’s general health), the focus of treatment is usually on trying to control the cancer. This can help with symptoms and may help people live longer. Treatment with radiation therapy and/or chemo may be helpful for some people.

For those who are jaundiced because of bile duct blockage, a stent or catheter may be placed in the duct to allow the bile to flow. If needed, surgery to bypass the bile duct may be an option if the person is healthy enough. Relieving bile duct blockage is often the first palliative treatment done, before starting other treatments such as chemo.

For people having pain, radiation therapy, alcohol injections to the nerves around the gallbladder, and pain medicines may all be helpful.

Because these cancers can be very hard to treat with current options, you might want to consider taking part in a clinical trial of new treatments.

Recurrent gallbladder cancer

Cancer is called recurrent when it comes back after treatment. Recurrence can be local (in or near the same place it started) or distant (spread to organs such as the lungs or bone). If the cancer comes back after initial treatment, further treatment depends on where the cancer recurs, what kind of treatment was previously used, and on the patient’s health. Rarely, the cancer may recur in a small area near where it started, in which case surgery to try to remove it (perhaps followed by chemo and/or radiation therapy) might be an option. But in most cases the recurrent cancer is unresectable and is treated as described above.

Recurrent gallbladder cancer is usually very hard to treat, so you might want to consider taking part in a clinical trial of new treatments.